Wernicke-Korsakoff syndrome, sometimes called cerebral beriberi, is a severe memory disorder usually associated with chronic excessive alcohol consumption, although the direct cause is a deficiency in thiamin (vitamin B1). It may also result from dietary deficiencies, prolonged vomiting, eating disorders, or the effects of chemotherapy medications.

Wernicke-Korsakoff syndrome was first identified in the late nineteenth century. Although Wernicke's and Korsakoff's may appear to be two different disorders, they are generally considered to be different stages of the same disorder, which is called Wernicke-Korsakoff syndrome.

Wernicke-Korsakoff syndrome includes Wernicke's encephalopathy and Korsakoff's syndrome (or Korsakoff's amnesic syndrome or Korsakoff's psychosis). Wernicke's encephalopathy is the first or acute phase of Wernicke-Korsakoff syndrome, and usually includes symptoms of acute mental confusion, ataxia (lack of coordination), and ophthalmoplegia (weakness or paralysis of the eye).

Korsakoff's syndrome represents the chronic (long-term) phase of the syndrome, which manifests as a memory disorder. Symptoms include amnesia, fabrication (making false statements) of memory, attention deficit, disorientation, and vision impairment. The main features of Korsakoff's syndrome are the impairments in acquiring new information or establishing new memories, and in retrieving previous memories. Korsakoff's syndrome is also known as alcohol-induced persisting amnestic disorder.

The estimated number of individuals with Wernicke-Korsakoff syndrome is between one and two percent of the population in the United States. Wernicke's encephalopathy is fairly rare, and accounts for about 0.05% of all hospital admissions, although this does not account for patients who do not seek medical attention.

Wernicke-Korsakoff syndrome usually follows many years of chronic alcoholism or malnutrition and is seldom seen among people less than 20 years of age. Most patients are 40 years of age or older. The disorder is apparently more common in alcoholic individuals who are particularly vulnerable to malnutrition such as indigent or homeless people.

Primary thiamin deficiency:
Primary thiamin deficiency is caused by inadequate intake of thiamin (vitamin B1). It is commonly due to a diet of highly refined carbohydrates (such as white rice, white flour, and white sugar) and processed foods. It also develops when intake of other nutrients is inadequate, including other B vitamin deficiencies.

Secondary thiamin deficiency: Secondary thiamin deficiency is caused by increased demand of the vitamin, due to conditions such as hyperthyroidism (high levels of thyroid hormone), pregnancy, lactation, strenuous exercise, fever, impaired absorption (as in prolonged diarrhea or irritable bowel syndrome (IBS), or impaired metabolism (such as due to hepatic or liver insufficiency or diabetes).

Age: The age of onset for developing
Wernicke-Korsakoff syndrome is evenly distributed from 30-70 years.

Alcohol abuse: Heavy alcohol use interferes with the break down of thiamine in the body. Even if an individual with alcoholism follows a well-balanced diet, most of the thiamine is not absorbed, and the individual may develop Wernicke-Korsakoff syndrome.

Poor diet/malnutrition: Eating processed foods (such as packaged meats and canned foods), food that contains too many refined carbohydrates (such as white breads, sweets, and other foods containing refined sugars), and white rice can cause thiamin deficiencies. Thiamin deficiency may result in the development of Wernicke-Korsakoff syndrome. Most developed nations add thiamin to some foods, such as flour and white rice.

Race:
No racial risk factors in Wernicke-Korsakoff syndrome are observed.

Thiamin deficiency: Thiamine deficiency is associated with two neurological disorders, beriberi and Wernicke-Korsakoff syndrome. Beriberi is caused by lack of dietary thiamine and its symptoms include myocardial (heart muscle) failure, reversible by thiamine treatment. Wernicke-Korsakoff syndrome is characterized by acute encephalopathy (brain disease) followed by chronic impairment of short-term memory. Wernicke-Korsakoff syndrome is most commonly observed in people with alcoholism since heavy drinkers often eat poorly and alcoholism interferes with absorption of nutrients from the digestive system. It can also occur in people who are malnourished.

Thiamin (vitamin B1) helps produce energy needed to make neurons function properly. Insufficient thiamin can lead to damage or death of neurons. Thiamin deficiency damages regions of the brain, particularly the thalamus and the mammillary bodies. This may disrupt the formation and storage of memories.

Wernicke's encephalopathy involves damage to multiple nerves in both the central nervous system (brain and spinal cord) and the peripheral nervous system (the rest of the body). It may also include symptoms caused by alcohol withdrawal.

Other causes: Wernicke-Korsakoff syndrome may also occur due to dietary deficiencies, brain trauma or stroke (neurological impairment resulting from a lack of oxygen to the brain), prolonged vomiting, eating disorders, starvation, uremia (buildup of toxins and waste in the urine), chronic (long-term) dialysis, prolonged intravenous (IV) therapy, gastric bypass or stapling, disseminated (spread over a large area) tuberculosis, or the side-effects of chemotherapy medications.

Symptoms in the acute phase of Wernicke-Korsakoff syndrome are nonspecific, meaning they are hard to detect. They include fatigue, irritability, poor memory, sleep disturbances, pericardial (heart) pain, anorexia, and abdominal discomfort.

Other primary symptoms of Wernicke's encephalopathy are mental confusion, eye movement disturbances, and ataxia (lack of coordination). Confusion and ataxia may resemble the effects of severe alcohol intoxication, but persist after intoxication wears off. Some individuals with Wernicke's encephalopathy will recover completely without residual memory deficits, particularly if they are treated quickly with thiamin.

The chronic stage of Wernicke-Korsakoff syndrome, sometimes called Korsakoff's syndrome is distinguished by anterograde amnesia (a condition where most new memories are not transferred to long-term). Most untreated individuals with Wernicke's encephalopathy will develop this severe memory disorder, which prevents them from forming lasting memories of events or information encountered after the onset of the initial symptoms. Symptoms of Korsakoff's syndrome may also develop spontaneously in many patients who never show signs of Wernicke's encephalopathy. Once patients develop Korsakoff's amnesia, recovery is unlikely.

Many individuals with Korsakoff's syndrome have some retrograde amnesia (loss of memory for past events) in addition to anterograde amnesia, particularly for events that occurred shortly before the onset of illness, but most can recall the distant past without difficulty.

Immediate memory is generally not affected. For instance, an individual with Korsakoff's syndrome could repeat a sequence of numbers immediately after hearing them, although this information would likely be forgotten within a very short period of time. Because immediate memory remains intact in individuals with Korsakoff's syndrome, they can interact with others, respond to questions, and develop conditioned reactions to stimuli.

Confabulation (falsification of memories) is another striking feature of Korsakoff syndrome, although it is not always observed. The individual appears to be making up stories to compensate for an inability to remember. Confabulation often seems to involve a confusion of the past and present.

Individuals with Korsakoff syndrome may also show signs of apathy (indifference), a lack of spontaneous behavior, meager content in conversation, and lack of insight. Emotional expression may be lacking as well.

Suicidal thoughts are not generally associated with this disorder, although any person in the midst of delirium may become self-injurious. Delirium is a sudden state of severe confusion and rapid changes in brain function, sometimes associated with hallucinations and hyperactivity, in which the individual is inaccessible to normal contact.

Individuals that are detoxifying from alcohol may present with varying degrees of alcohol withdrawal, including delirium tremens (DTs) and hallucinations. Individuals with alcoholism-induced Wernicke-Korsakoff syndrome may present with symptoms of alcohol withdrawal that can be confused with those of the syndrome. Symptoms of alcohol withdrawal (delirium tremens) include tremors, irritability, confusion, stupor, and hallucinations. Patients experiencing symptoms of alcohol withdrawal should receive appropriate treatment to reduce the risk of seizures.

The presence of anterograde amnesia (loss of memory of present events) and a history of chronic (long-term) heavy drinking, or malnutrition suggest a diagnosis of Korsakoff's syndrome. When Korsakoff's syndrome follows a previous diagnosis of Wernicke's encephalopathy, the entire Wernicke-Korsakoff syndrome diagnosis is appropriate.

Diagnosis can be confirmed by neuroimaging (brain imaging) or when autopsy after death findings show degeneration of parts of the brain including the thalamus and mammillary bodies, along with loss of brain volume in the area surrounding the fourth ventricle (a fluid-filled cavity near the brainstem). Changes in brain structure and function are found with neuroimaging.

Mental status: Mental status changes are present in 90% of patients and appear in various forms. For a diagnosis of Wernicke-Korsakoff's syndrome, memory impairment must significantly inhibit an individual's ability to perform normal activities and functions and it must represent a decline from a previous level of functioning. Amnesia does not occur exclusively during states of delirium, alcohol intoxication, or withdrawal, nor is it exclusively associated with dementia. Individuals with Wernicke-Korsakoff syndrome frequently demonstrate problems with executive functions, contributing to the symptoms of confusion and apathy.

Physical examination: Physical examination of the nervous/muscular systems may show decreased reflexes and impaired gait and coordination. Muscles may be weak and may show atrophy (loss of tissue mass). Examination of the eyes may show abnormalities of eye movement. Blood pressure and body temperature measurement may be low. Pulse (heart rate) may be rapid.

Blood tests: Blood tests used to check an individual's nutrition status include serum B1 (thiamin) levels, along with liver function. Blood or urine alcohol levels and liver enzymes, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are usually tested and may be high if the individual has a history of chronic (long-term) alcohol abuse. Blood tests may include electrolytes (including sodium, potassium, and chloride).

Blood tests may also be done to rule out other chronic conditions that may cause thiamin deficiency including acquired immunodeficiency syndrome (AIDS), hyperemesis gravidarum (continuous nausea and vomiting during pregnancy), thyrotoxicosis (very high thyroid hormone levels), cancers that have metastasized (spread), long-term dialysis in kidney problems, and congestive heart failure (CHF, or the inability of the heart to pump the blood) when treated with long-term diuretic therapy.

Neuroimaging: Computerized tomography (CT) scans may help in rapid assessment to rule out hemorrhage (bleeding), edema (swelling), and sub-acute stroke (neurological damage due to lack of oxygen to the brain). A brain magnetic resonance imaging (MRI) study rarely shows changes in the tissue of the brain indicating Wernicke-Korsakoff syndrome. However, MRIs can detect acute lesions of Wernicke-Korsakoff syndrome in regions of the brain.

Mental complications: Mental complications from
Wernicke-Korsakoff syndrome include a permanent loss of memory, permanent loss of cognitive skills, injuries caused by falls, and difficulty with personal or social interaction.

Other complications: Hypothermia (low body temperature) may occur when there is damage in the temperature regulating centers of the brain. Peripheral neuropathy (damage to nerves that cause tingling and numbness in hands or feet) is found in 80% of patients and may be permanent. Cardiovascular or heart problems, such as congestive heart failure or CHF, may be observed. Individuals may also experience alcohol withdrawal (if caused by alcohol) and a shortened life span.

General:
The goals of treatment are to control symptoms and prevent progression of the disorder. Hospitalization is usually required for initial control of symptoms.

If the individual is lethargic, unconscious, or comatose, monitoring and care appropriate to the condition may be required.

Total abstinence or completely stopping drinking alcohol is required to prevent progressive loss of brain function and damage to peripheral nerves. A well-balanced, nourishing diet including fresh fruits and vegetables and less red meats and processed, refined foods is recommended.

Patients are usually dehydrated (lack of water) and so re-hydration to restore blood volume should be started. Glucose depletes thiamine stores in the brain, which can acutely worsen Wernicke's encephalopathy.

A thiamin (vitamin B1) injection may improve symptoms of confusion or delirium, difficulties with vision and eye movement, and muscle in-coordination. Vitamin B1 may be given by injection into a vein or a muscle or by mouth. Thiamine does not generally improve loss of memory and intellect associated with Korsakoff psychosis.

Patients usually continue taking thiamine supplementation, as well as other vitamins and electrolytes, until a well-balanced diet can be maintained. Long-term supplementation may be required in patients who cannot maintain adequate nutritional intake, whether from noncompliance or an underlying disorder.

Treatments to improve memory:

Medications: Recent reports suggest that donepezil (Aricept®) and rivastigmine (Exelon®), drugs used to treat Alzheimer's
disease, may improve memory in patients with Wernicke-Korsakoff syndrome. Both drugs prevent the breakdown of the neurotransmitter acetylcholine, which is important for the formation of memories. Individuals treated with these drugs showed improvements on memory tests and were more able to recognize hospital staff and family members. Although improvements appear to be rather modest, these drugs may be useful for patients who do not respond to thiamin. Side effects can include nausea, vomiting, diarrhea, loss of appetite, tiredness, drowsiness, trouble sleeping, or muscle cramps.

Antidepressants that increase levels of serotonin, including the serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac®) and sertraline (Zoloft®), may also be helpful although the reasons why are not clear since these drugs are not effective with other memory disorders. Side effects include drowsiness and fatigue (tiredness).

Conditioning: Researchers have explored the use of classical conditioning procedures in helping patients to remember specific people. In classical conditioning, animals and people learn to associate a stimulus with an outcome. The most famous example is the pairing of a ringing bell with food. Dogs naturally salivate when given food. In a famous experiment, Ivan Pavlov rang a bell immediately before serving food to dogs. After doing this repeatedly, Pavlov found that the dogs salivated upon hearing the bell ring even when the food was not presented. This form of learning does not rely on the hippocampus and cortex but appears to involve neurons in other parts of the brain. Patients with Wernicke-Korsakoff syndrome who are given specific rewards for correctly choosing a picture of a face that matches a face they have seen previously are more able to choose the correct face than those who do not receive the rewards. Although these individuals do not explicitly remember the face they saw previously, they are still able to make the correct choice. Training patients in this way could enable them to recognize familiar people and differentiate them from strangers.

Treatment of alcoholism:

Abstinence from alcohol provides the best chance for recovery or slowed progression of Wernicke-Korsakoff syndrome associated with alcoholism.

Medications:
In conjunction with thiamine replacement, medications for alcohol detoxification include benzodiazepines such as chlordiazepoxide (Librium®) and diazepam (Valium®) and anticonvulsants such as carbamazepine (Tegretol®) and valproic acid (Depakene®, Depakote®). Medications for maintaining alcohol abstinence include disulfiram (Antabuse®) and acamprosate (Campral®).

Counseling and support:
Individuals should seek counseling for alcoholism, which includes twelve-step programs and other support groups.

Prognosis: The prognosis for full recovery from Wernicke-Korsakoff syndrome is poor. Once chronic Korsakoff's amnesia ensues, approximately 80% of patients will never fully recover the ability to learn and remember new information. Because they cannot learn from experience, individuals with Wernicke-Korsakoff syndrome almost always require some form of custodial care. They are usually unable to work, although some can perform simple tasks they learned prior to onset of the condition if closely supervised.

Note: Currently, there is a lack of scientific data on the use of integrative therapies for the treatment or prevention of Wernicke-Korsakoff syndrome. The integrative therapies listed below should be used only under the supervision of a qualified healthcare provider and should not be used in replacement of other proven therapies or preventive measures.

Strong scientific evidence:

Ginkgo: Ginkgo biloba has been used medicinally for thousands of years. The scientific literature overall does suggest that ginkgo may benefit people with dementia, and may be as helpful as acetylcholinesterase inhibitor drugs such as donepezil (Aricept®). Well-designed research comparing ginkgo to prescription drug therapies is needed.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Sage: Sage has long been suggested as a possible therapy for memory and cognitive improvement. Several trials provide evidence for the use of sage for this indication. Additional study is needed to confirm these findings and determine the best dose.

Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae (mint) family. Use cautiously with hypertension (high blood pressure). Use sage essential oil or tincture cautiously in patients with epilepsy. Avoid if pregnant or breastfeeding.

Good scientific evidence:

5-HTP: 5-HTP is the precursor for serotonin. Serotonin is the brain chemical associated with sleep, mood, movement, feeding, and nervousness. Cerebellar ataxia results from the failure of part of the brain to regulate body posture and limb movements. 5-HTP has been observed to have benefits in some people who have difficulty standing or walking due to cerebellar ataxia. However, current evidence is mixed. Further research is needed before a strong conclusion can be drawn.

Avoid 5-HTP if allergic or hypersensitive to it. Signs of allergy to 5-HTP may include rash, itching, or shortness of breath. Avoid with eosinophilia syndromes, Down syndrome, or mitochondrial encephalomyopathy. Use cautiously if taking antidepressant medications, 5-HTP receptor agonists, carbidopa, phenobarbital, pindolol, reserpine, tramadol, or zolpidem. Use cautiously with kidney insufficiency, HIV/AIDS (particularly HIV-1 infection), epilepsy, or with a history of mental disorders. Avoid if pregnant or breastfeeding.

Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine (medicine practiced in India) and is widely used in India for enhancing memory, pain relief, and treating epilepsy. Although bacopa is traditionally used in Ayurvedic medicine to enhance cognition, high-quality clinical trials are lacking.

Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin®), and drugs metabolized by the liver. Use cautiously
with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents or any member of the Scrophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.

Music therapy: Music is used to influence physical, emotional, cognitive and social well-being and improve quality of life for healthy people as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. In people with dementia and other mental disorders, music therapy has been found to reduce aggressive or agitated behavior, improve mood, and improve cooperation with daily tasks such as bathing. Music therapy may also help maintain mental performance. Music therapy is generally known to be safe.

Unclear or conflicting scientific evidence:

Acupuncture: Acupuncture is commonly used throughout the world. According to Chinese medicine theory, the human body contains a network of energy pathways through which vital energy, called "chi," circulates. These pathways contain specific points that function like gates, allowing chi to flow through the body. Needles are inserted into these points to regulate the flow of chi. Various types of acupuncture, such as scalp acupuncture and traditional acupuncture have been used to treat hemiplegia. More study is needed before a recommendation can be made.

Acupuncture has been reported to help improve memory and cognitive performance in the elderly. However, there is currently insufficient available evidence for the use of acupuncture in cognitive disorders and communication disorders. There is also insufficient evidence to recommend the use of acupuncture in the treatment of vascular dementia. More research is necessary.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with a history of seizures.

Arginine: There is not enough information available to make a strong recommendation about the use of the amino acid arginine in senile dementia. Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease.

Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

Ayurveda: The herb Brahmi (Bacopa monnieri) is used in many Ayurvedic preparations for a variety of ailments. There is evidence from well-designed studies that it may improve memory and cognitive function in adults. Another study suggests that the herbal preparation Maharishi Amrit Kalash (MAK) -4 may enhance attention capacity or alertness, and thus reverse some of the detrimental cognitive effects of aging. Further research is needed to confirm these results.

Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long period of time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs may interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before use. Use guggul cautiously with peptic ulcer disease. Patients should avoid sour food, alcohol, and heavy exercise with use of this herb. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia chebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.

Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine and is widely used in India for enhancing memory, pain relief, and treating epilepsy. However, additional study is needed before a firm conclusion can be drawn.

Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin®), and drugs metabolized by the liver. Use cautiously
with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents, or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.

Beta-carotene: Antioxidants such as beta-carotene may be helpful for increasing cognitive performance and memory. Long-term, but not short-term, beta-carotene supplementation appears to benefit cognition.

Avoid if sensitive to beta-carotene, vitamin A, or any other ingredients in beta-carotene products.

Black tea: Several preliminary studies have examined the effects of caffeine, tea, or coffee use on short and long-term memory enhancement. It remains unclear if tea is beneficial for this use. Limited, low-quality research also reports that the use of black tea may improve mental performance/alertness and cognition. Black tea contains caffeine, which is a stimulant.

Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.

Boron: Preliminary human studies report better performance on tasks of eye-hand coordination, attention, perception, short-term memory, and long-term memory with the use of boron. Boron may be beneficial in improving cognitive function, however, additional studies are needed.

Chromium: Early research suggests that chromium picolinate may help improve cognitive function in the elderly. Further study is needed in this area.

Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke, and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.

Cranberry: Preliminary study results show that cranberry juice may increase overall memory enhancement. Further well-designed clinical trials are needed to confirm these results.

It is best not to use sweetened cranberry juice or cranberry juice cocktail due to the high sugar content. The use of 100% cranberry juice products is recommended by healthcare providers. Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.

Creatine: Numerous studies suggest that creatine may be helpful in the treatment of various neuromuscular diseases. Early studies show also that creatine may improve memory in certain populations. Further research is required before recommendations can be made.

Avoid if allergic to creatine or if taking diuretics. Use cautiously with asthma, diabetes, gout, kidney disorders, liver or muscle problems, stroke, or with a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.

DHEA: Dehydroepiandrosterone (DHEA) is an endogenous hormone (made in the human body) and secreted by the adrenal gland. DHEA serves as precursor to male and female sex hormones (androgens and estrogens). DHEA levels in the body begin to decrease after age 30 and may need to be taken as supplements. Preliminary evidence, from a controlled trial and a case series, gives conflicting results as to whether DHEA offers benefit to individuals with dementia. Well designed clinical trials, with appropriate endpoints are required before recommendations can be made.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Ginkgo: There is preliminary research showing small improvements in memory and other brain functions with use of ginkgo in patients with age-associated memory impairment (AAMI), although some studies disagree. Overall, there is currently not enough clear evidence to recommend for or against ginkgo for this condition. It remains unclear if ginkgo is effective for memory enhancement in healthy patients. Further well-designed research is needed as existing study results conflict.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily.
If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Ginseng: The roots of ginseng have been valued in Chinese medicine for more than 2,000 years. Clinical research found that patients with neurological disorders may improve when taking Panax ginseng. Early small studies report that Fuyuan mixture, an herbal combination that contains ginseng, may improve symptoms of multi-infarct dementia. The effects of ginseng alone are not clear, and no firm conclusion can be drawn. In addition, the use of ginseng for mental performance has been assessed using standardized measurements of reaction time, concentration, learning, math, and logic. Benefits have been seen both in healthy young people and in older ill patients.

Avoid with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

Gotu kola: Ayurveda regards gotu kola (Centella asiatica) as an important rejuvenating herb for nerve and brain cells, believed to be capable of increasing intelligence, longevity, and memory. Limited available clinical study investigated a combination product containing gotu kola on cognitive function in the elderly, but did not find any benefit. Additional study is needed to confirm these findings.

Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer, or diabetes. Avoid if pregnant or breastfeeding.

Green tea: Several preliminary studies have examined the effects of caffeine, tea, or coffee use on short and long-term memory and cognition. It remains unclear if tea is beneficial for this use. Limited, low-quality research reports that the use of green tea may improve cognition and mental performance/alertness.

Green tea contains caffeine, which is a stimulant. Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.

Guarana: Guarana is a native species of South America and has stimulating properties when taken by mouth. Guarana is also used to enhance athletic performance and to reduce fatigue. Guarana has not been shown to alter cognitive enhancement or arousal in preliminary studies. Caffeine found in guarana may improve simple reaction time, but may not improve immediate memory. Additional study is needed in this area.

Avoid if allergic/hypersensitivite to guarana (Paullinia cupana), caffeine, tannins, or species of the Sapindaceae family. Avoid with hypertension, psychological or psychiatric disorders, liver impairment, and arrhythmias. Avoid with other stimulatory agents, especially ephedra. Use cautiously with breast disease, impaired kidney function, diabetes, pre-existing mitral valve prolapse, iron deficiency, gastric or duodenal ulcers, bleeding disorders, glaucoma or if at risk for osteoporosis. Use cautiously if undergoing electroconvulsive therapy (ECT). Avoid if pregnant or breastfeeding.

Guided imagery: The term guided imagery may be used to refer to a number of techniques, including metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Early research suggests that guided imagery of short duration may improve working memory. Further research is needed before a firm conclusion can be drawn.

Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified healthcare provider if mental or physical health is unstable. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms. In patients feeling unusually anxious while practicing guided imagery, or in patients with a history of trauma or abuse, a qualified health care provider should be consulted before practicing guided imagery.

Jasmine: Odors and memory improvement are considered to be somehow linked in the brain. Two clinical trials using weakly jasmine-scented rooms found that subjects did not have improved recall of a physical environment without the jasmine odor trigger but could remember a word list better when exposed to a jasmine trigger. More research is needed in this area.

Use cautiously during pregnancy, based on traditional use. Use cautiously in patients allergic to jasmine, jasmine oil, or other fragrances. Use cautiously during lactation as jasmine flowers applied to the breasts have been used as a lactofuge. Avoid oral consumption of essential oils, including jasmine essential oil, as they are extremely potent and can be poisonous.

Jojoba: Jojoba oil is traditionally used as a carrier or massage oil. There is currently not enough available evidence to recommend for or against the use of jojoba oil for dementia.

Avoid if allergic or hypersensitive to jojoba, its constituents, or members of the Simmondsiaceae family. Avoid oral consumption of jojoba products. Avoid if pregnant or breastfeeding.

Khat: Khat is a flowering evergreen plant that has been grown for use as a stimulant for centuries. Khat has been evaluated for its benefits for cognitive function; however, the results are mixed with some studies showing benefit and others showing negative effects. Additional study is needed to clarify these findings.

When taken by mouth, it is unknown whether khat is physically addictive. However, it is linked to psychological dependence and is illegal in the United States. Avoid if allergic to the Celastraceae family (staff vine family). Use cautiously if taking amoxicillin, ampicillin or stimulants. Use cautiously with a history of high blood pressure, fast heartbeat (tachycardia), depression, or motor tics (Tourette's syndrome). Avoid with glaucoma or mental illness. Avoid driving or operating heavy machinery after using khat. Avoid holding khat in the cheek for a long time. Avoid if pregnant or breastfeeding.

Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. Breathing exercises are an important part of Kundalini yoga. There is some evidence from studies with healthy volunteers that use of certain breathing techniques (such as breathing solely through one nostril or the other) may improve different aspects of cognitive function. More studies are needed to determine if these techniques can reliably be used to improve cognitive function and possibly aid in treating cognitive and nervous system disorders.

Avoid exercises that involve stoppage of breath, with heart or lung problems, insomnia, poor memory, or concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Use cautiously with mental disorders as some techniques may cause an altered state of consciousness. Kundalini Yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Lamaze techniques are based on yogic breathing. If started early in the pregnancy, it may be possible to master the ability of breathing to reduce stress and aid in labor. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.

Lavender: Although lavender is a sedative-type aroma, use during recess periods in a work environment after accumulation of fatigue seemed to prevent deterioration of cognitive performance in subsequent work sessions. Small trials investigating the effects of lavender aromatherapy on agitation and behavior in patients with dementia report conflicting results. Further well-designed studies are needed before a conclusion can be drawn.

Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

L-Carnitine: Most studies of L-carnitine related to dementia suffer from various weaknesses. Although preliminary evidence is promising, there is insufficient available evidence to recommend for or against this use. There are also a limited number of studies relevant to the use of carnitine for memory. Carnitine does not appear to have any effect on memory.

Additional study is needed before a conclusion can be made. Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

Lemon balm: Clinical data suggest that the use of standardized lemon balm (Melissa officinalis) extract has some effect on particular self-reported measures of mood and cognitive performance. More rigorous studies need to be conducted using patient-relevant outcomes to better assess the validity of these results as they apply to patient care.

Avoid if allergic or hypersensitive to lemon balm. Avoid with Grave's disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.

Macrobiotic diet: Macrobiotics is a predominantly vegetarian, whole-foods diet that emphasizes whole grains (especially brown rice), vegetables, fruits, legumes, and seaweeds. The evidence is mixed as to whether or not a macrobiotic diet helps, hinders, or has no effect on cognitive function in children.

There is a risk of nutrition deficiencies with use of an exclusive macrobiotic diet; however, this can be avoided with appropriate menu planning. Use cautiously with cancer or other medical conditions without expert planning or supplementation. Macrobiotic diets are not recommended in children or adolescents without professional guidance or appropriate supplementation, and are also not recommended in pregnant or lactating women due to potential deficiencies, unless properly supplemented.

Massage: Massage with or without essential oils has been used in patients with dementia in chronic care facilities to assess effects on behavior. There is compelling early evidence that aromatherapy with essential oils may reduce agitation in patients with dementia, although the effects of massage itself are not clear.

Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

Meditation: Some forms of meditation may have positive effects on cognitive function. However, there is not enough clear evidence that any specific form of meditation can support or enhance cognitive function.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

Moxibustion: Moxibustion uses the principle of heat to stimulate circulation and break up congestion or stagnation of blood and chi (energy). Early evidence suggests an integrated protocol of herbs, acupuncture, moxibustion, and Western medicine may benefit patients with peripheral facial paralysis. However, there is currently insufficient evidence on which to base concrete conclusions at this time.

Avoid with aneurysms, any kind of "heat syndrome," heart disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, or inflammatory conditions. Avoid areas with an inflamed organ, contraindicated acupuncture points, allergic skin conditions, ulcerated sores, or skin adhesions. Avoid over the face, genitals, head, or nipples. Avoid in patients who have just finished exercising or taking a hot bath or shower. Avoid if pregnant or breastfeeding. Use cautiously over large blood vessels and thin or weak skin. Use cautiously with elderly people with large vessels. It is considered not advisable to bathe or shower for up to 24 hours after a moxibustion treatment.

Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, or linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

Physical therapy: The goal of physical therapy is to improve mobility, restore function, reduce pain, and prevent further injury. A variety of techniques, including exercises, stretches, traction, electrical stimulation, and massage, are used during physical therapy sessions. Based on available evidence, it is unclear if physical therapy is beneficial for neurological disorders.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature, although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used during pregnancy, and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Reiki: Early research suggests that Reiki therapy may improve behavioral and memory problems in patients with mild cognitive disorders. However, additional studies are needed to confirm these findings.

Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.

Rhodiola: Early human study suggests that rhodiola may benefit learning, memory, and mental performance. Well-designed studies are needed before a recommendation may be made.

Avoid if allergic or sensitive to Rhodiola. Use cautiously in people with diabetes, cardiovascular disease, or neurological or psychiatric disorders. Rhodiola is not recommended for use during pregnancy or breastfeeding.

Rhubarb: Preliminary study has investigated rhubarb along with other herbs in the treatment of age-associated memory impairment (AAMI). Studies of rhubarb alone are needed to discern rhubarb's effect on aging and memory.

Avoid if allergic/hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis, and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking anti-psychotic drugs or oral drugs, herbs or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.

Riboflavin: Adequate nutrient supplementation with riboflavin (vitamin B2) may be required for the maintenance of adequate cognitive function. Treatment with B-vitamins including riboflavin has been reported to improve scores of depression and cognitive function in patients taking tricyclic antidepressants. This may be related to tricyclic-caused depletion of riboflavin levels.

Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as safe during pregnancy and breastfeeding. The U.S. Recommended Daily Allowance (RDA) for riboflavin in pregnant women is higher than for non-pregnant women, and is 1.4 milligrams daily (1.6 milligrams for breastfeeding women).

Soy: It is unclear if soy isoflavone supplementation in postmenopausal women may improve cognitive function. Results from studies are mixed.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy.

Taurine: Taurine, or 2-aminoethanesulfonic acid, was originally discovered in ox (Bos taurus) bile and was named after taurus, or bull. In the diet, taurine is considered to be a non-essential amino acid, although it is not a true amino acid. Preliminary study indicates that taurine supplementation may result in improvements in symptoms of myotonic dystrophy. Although promising, additional study is needed to confirm these findings.

Taurine is an amino acid, and it is unlikely that there are allergies related to this constituent. However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously in patients with high cholesterol, low blood pressure, bleeding disorders, potential for mania, or epilepsy. Avoid consuming energy drinks containing taurine, caffeine, glucuronolactone, B vitamins, and other ingredients before drinking alcohol or exercising. Use cautiously if pregnant or breastfeeding because taurine is a natural component of breast milk.

TENS (transcutaneous electrical nerve stimulation): Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Based on the available evidence, it is unclear if TENS is an effective treatment for hemiplegia.

Avoid with implantable devices, such as defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation (such as neuropathy) or with seizure disorders. Avoid if pregnant or breastfeeding.

Traditional Chinese medicine: Traditional Chinese medicine (TCM) herbal combinations have been used for the treatment of dementia and reportedly improve cognitive function and activities of daily living. More studies of better design are needed before recommendations can be made.

Acupuncture is generally considered safe. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurologic disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Turmeric: Curcumin has been shown to have antioxidant and anti-inflammatory properties and to reduce beta-amyloid and plaque burden in lab studies. However, there is currently not enough evidence to suggest the use of curcumin for cognitive function.

Avoid if allergic or hypersensitive to turmeric, curcumin, yellow food colorings, or plants belonging to the Zingiberaceae (ginger) family. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, diabetes, hypoglycemia, or gallstones. Use cautiously with blood-thinners, such as warfarin (like Coumadin®), and blood sugar-altering medications. Avoid in medicinal amounts if pregnant or breastfeeding. Turmeric should be stopped prior to scheduled surgery.

Vitamin B6: Major sources of vitamin B6 include cereal grains, legumes (beans), vegetables (like carrots, spinach, peas), potatoes, milk, cheese, eggs, fish, liver, meat, and flour. There is preliminary evidence that pyridoxine supplementation might benefit hyperkinetic children who have low levels of serotonin in their blood. Further research is needed to better understand the role of vitamin B6 for hyperkinetic disorders.

Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). Avoid if sensitive or allergic to any vitamin B6 product ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Use cautiously if pregnant or breastfeeding.

Vitamin E: Vitamin E has been proposed and evaluated for the prevention or slowing of dementia, based on antioxidant properties and findings of low vitamin E levels in some individuals with dementia. Overall, the evidence remains inconclusive in this area.

Vitamin E may cause bleeding, especially in sensitive individuals such as those taking medications for bleeding disorders (including warfarin or Coumadin®). Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid use above the recommended daily level in pregnant and breastfeeding women.

Fair negative scientific evidence:

Bitter orange: Bitter orange has been used in aromatherapy, although it does not appear to reduce combative, resistive behaviors in individuals with dementia. Currently, evidence supporting the use of bitter orange for dementia and behavioral challenges is lacking.

Choline: Choline is an essential amino acid that is produced in the body and consumed in the diet. Choline is possibly ineffective when taken by mouth for treating cerebellar ataxia.

DHEA: Studies of the effects of dehydroepiandrosterone (DHEA) on memory have produced complex and inconsistent results. Additional study is warranted in this area.

Ginkgo: The results of limited available study investigating the effect of Ginkgo biloba on post-prandial mental performance are unclear. Ginkgo may benefit some but not all endpoints. Further clinical trials are required before a conclusion can be made.

The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.